Curing Medicare

Front matter

CURING MEDICARE

A Doctor's View on How Our Health Care System Is Failing Older Americans and How We Can Fix It

ANDY LAZRIS, MD

Contents

Foreword by Shannon Brownlee

Acknowledgments

Introduction: My Boss

FoREWORD

When Congress passed the Medicare Act in 1965, it was the culmination of one of the most bitter, divisive, and drawn-out battles in congressional history. The need for Medicare legislation was abundantly clear. In 1965, only half of the more than thirteen million Americans over the age of sixty-five had any form of health insurance. Two-thirds had incomes of less than $1,000 a year and many older Americans were living and dying without benefit of any medical care at all. Yet the American Medical Association (AMA), whose a third less than the rest of the population— principal worry about Medicare was a decline in physician incomes, would spend $50 million over a decade campaigning against what it called at various points a “dangerous device, invented in Germany,” a “communist plot,” and “socialized medicine.” Together with the hospital and insurance industries, the AMA successfully fought off legislation until the 1964 elections brought a majority Democratic Congress and President Lyndon

Johnson into office.

x Foreword

Today, Medicare is rightly seen by many as one of the greatest social programs of the twentieth century and a cornerstone of Johnson’s “Great Society.” It made health care available to millions of elderly citizens, spurred the desegregation of hospitals in the South, and brought down infant mortality rates. Medicare and its sister program Medicaid, which covers the disabled as well as poor children and pregnant women, together provide health insurance coverage to more than eighty million Americans. Yet the politics of Medicare’s passage, and the compromises made to appease private insurers, hospitals, and the AMA, set the stage for the rise of the medical industrial complex, to quote the phrase coined by a former editor of the New England Journal of Medicine, and can be linked to many of the ills that beset it today.

Among the most tragic of these ills is the way in which elderly, frail, chronically ill Americans are treated by our health care system. When old people who are suffering one or more debilitating chronic illnesses take a fall, feel dizzy, grow confused, or have trouble breathing, they often find themselves on a slippery chute leading straight into the hospital, which has become the default site of care. About a third of U.S. deaths occur in the hospital, despite the fact that the vast majority of Americans say they prefer to die at home.' Nearly 17 percent of deaths among Medicare recipients include a stay in the intensive care unit.’ No matter how fervently patients and their families might wish to avoid invasive treatment as increasing frailty and death approach, and no matter how clearly they have laid out their wishes in an advance directive, the hospital continues to be the site of easiest and first resort, And as Andy Lazris shows in this fine book, nothing a good doctor can say, nothing he can do will change the fact that all too often the way we care for the frail elderly in this country causes untold harm and suffering, and may even be shortening lives.

There are many reasons for this ill-treatment, chief among them a culture of more that assumes there can be no such thing as too much medical intervention. This culture is reinforced by marketing messages from the pharmaceutical industry, which bombard doctors and patients alike. Doctors are rewarded by Medicare (and private insurers) on the basis of socalled “quality” metrics that have been implemented over the last decade in an effort to counter rampant overtreatment but often bear no relationship to the actual health of patients. In this book, much of the author’s frustration is aimed at these metrics and the numerous regulatory fixes

Foreword xi

Medicare has put in place over the last fifty years to remedy the consequences of compromises that were made to get the legislation passed.

Among the most powerful of these compromises involves the way hospitals are paid. For nearly two decades after Medicare’s passage, hospitals were “reimbursed” on a cost-plus basis: each year’s payments were based on the costs a hospital reported for several previous years. Like Pentagon suppliers, hospitals were given little incentive to be efficient and every reason to run up the bill. They did this by keeping patients in the hospital for as long as possible, buying new equipment, and expanding the number of beds and staff. Just a year after the legislation was enacted, a report to Congress stated that Medicare’s system for paying hospitals “contains no incentives whatsoever for good management and almost begs for poor management.”

The legacy of this policy, which lasted until Medicare switched in 1983 toa modified payment model called the diagnostic related group, or DRG, has been the creation of a massive technology-heavy, specialist-centric, hospital-based health care system, with comparatively little investment in community-based primary care. This runs counter to the best models in other high-income countries, where primary care forms the bedrock of health care. In America, hospital services are what the medical industrial complex has been built to offer, and that’s what it delivers.’ Highly invasive “rescue” care is the job for which young doctors and nurses are trained. Not surprisingly, the United States has some of the best, if not the best, acute care in the world. If you are going to get in a car accident, do it here. But acute care is often not what the elderly and chronically ill need.

In an effort to address rising rates of hospitalization and unsustainable costs, Medicare has over the years issued a host of regulations and new benefits for beneficiaries, such as hospice and skilled nursing facilities (SNFs), which were intended to encourage the use of lower-cost, non—hospital-based services. It has not quite worked out that way. For example, the use of SNFs and hospice is often associated with more hospitalization, not less.°

The reasons these regulations and benefits have failed to improve care are many, as Lazris and others have made clear. For example, Medicare part B, which covers such services as physician visits, tests, and physical therapy, does not pay for meaningful home care. The home hospice benefit pays for visits from a health care professional but not for home hospice aids.

For beneficiaries who have purchased supplemental insurance, Medicare xii Foreword part A makes a hospital admission the cheapest route even for a complaint that can be remedied at home, a doctor’s office, or in the nursing home. Weorst of all, for too many elderly people, hospitalization leads to tragic consequences. Statistics, it has been said, are people with the tears wiped away. This book movingly depicts those people: patients who become confused, agitated, and delusional in the hospital; polypharmacy leading to adverse drug reactions; unwanted deaths in the ICU; agitated patients who are “restrained”—doctor code for tied to the bed by the wrists—to prevent them from pulling out tubes or getting out of bed. These are just a few of the ways that aggressive care for the frailest and oldest cause needless suffering and drive up health care costs.

Market fundamentalists may conclude from this book that the problem lies with too much government regulation and that Adam Smith’s invisible hand can provide the fix. Let the elderly buy private insurance; for those who are too poor, provide a “defined benefit.” But this is no solution. The health care that is paid for through private insurance is no better organized than health care purchased through Medicare. A truly free market would take us back to 1964, when millions suffered and died because they lacked all access to medical treatment.

If Americans are not prepared to simply throw old people to the mercy of the marketplace, and polls suggest that most are not, rising costs will soon force us to grapple with the question of how we want to care for the sickest and most vulnerable among us. For the past fifty years, both Medicare payment policies and the taxpayer dollars that go toward the training of doctors and nurses have supported the expansion of our hospital-centric system while starving the community-based social and medical services that would improve the lives of millions of elderly Americans. We have not built the infrastructure that is needed to deliver the “high touch” care that could allow many more elderly people to age in place in their homes. We waste billions on useless or unwanted hospital care for the elderly, while failing to provide regular meal delivery or aides to help with house cleaning and bathing, simple services that can help an elderly person preserve autonomy and dignity. We are not training health care professionals to talk to patients and families to ensure that the care they receive is in line with their wishes for the declining years of their lives. We have too many specialists in many parts of the country and too few primary care doctors practicing in the community—ain part because our teaching hospitals make

Foreword xiii more money when they train more specialists. The primary care doctors we do have are not rewarded for making house calls and are often too busy to leave their offices in any case.

Shifting toward a community-based health care delivery system will require public investment and massive redirection of money and resources. That’s something the $3 trillion behemoth that is U.S. health care will not readily accept, and it will take enormous political will to make it happen. But happen it must. Baby boomers with aging and dying parents are experiencing firsthand the failures of our system. Let’s hope self-interest compels them to begin advocating, and soon, for better care for themselves. In the meantime, it is my hope that every policy maker and legislator in the country reads this book. It is not a conservative attack on the system written by a physician who would like to see Medicare disappear. It is a first-hand account from a committed doctor, who sees in the tears that lie behind the statistics the need for a transformed system.

Shannon Brownlee

ACKNOWLEDGMENTS

Thanks to Suzanne Gordon, my editor, who helped me work through the book to make it both stronger and more impactful. Her suggestions and additions were invaluable.

Thanks to Bob Duggan for helping me throughout the entire writing and marketing process, and for being a strong advocate for the book. Thanks to the progressive and forward-thinking organizations to which I belong, including the Lown Institute, the National Physicians Alliance, and the American Medical Directors Association.

CURING MEDICARE